Stroke recurrence rates among patients with symptomatic intracranial vertebrobasilar stenoses: systematic review and meta-analysis.

BACKGROUND: A recent randomized trial of patients with primarily anterior circulation intracranial artery stenosis showed that intensive medical therapy was superior to intracranial stenting in preventing recurrent stroke. The rate of stroke recurrence or death in symptomatic intracranial vertebrobasilar stenosis with medical therapy alone may be especially high, and rates compared with endovascular therapy need further study. METHODS: We conducted a systematic review and meta-analysis of studies reporting the rates of stroke recurrence or death (the primary outcome) in symptomatic intracranial vertebrobasilar stenosis with medical or endovascular treatment over a minimum follow-up period of 6 months. We included all studies in any language indexed in MEDLINE or EMBASE, supplemented by bibliography searches and by contacting the authors. The secondary endpoints were stroke recurrence, and basilar artery and vertebral artery stroke recurrence rates. RESULTS: 23 studies (592 medical treatment patients and 480 endovascular treatment patients) were included. The risk of combined stroke recurrence or death was 14.8 per 100 person-years (95% CI 9.5 to 20.1) in the medical group compared with 8.9 per 100 person-years (95% CI 6.9 to 11.0) in the endovascular group. The incidence rate ratio was 1.3 (95% CI 1.0 to 1.7). The stroke recurrence rate was 9.6 per 100 person-years (95% CI 5.1 to 14.1) in the medical group compared with 7.2 per 100 person-years (95% CI 5.5 to 9.0) in the endovascular group. CONCLUSIONS: Our results showed that the risk of stroke recurrence or death or the risk of stroke recurrence alone was comparable between the medical and endovascular therapy groups. A small preventive effect of endovascular therapy may exist, particularly if the 30 day postprocedural risk is reduced.

Two for one: surgical skills and CanMEDS roles--a combined course for surgical residents.

BACKGROUND: The purpose of this study was to develop a surgical skills program for first-year surgical residents by integrating the Canadian Medical Education Direction for Specialists (CanMEDS) roles. METHODS: A 9-week course combining basic surgical skills and CanMEDS roles was developed and provided to 24 residents from the Departments of Surgery and Obstetrics and Gynecology at the University of Calgary. Sessions consisted of a pretest/posttest, teaching the surgical skills, supervised practice, posttest, and teaching CanMEDS roles. RESULTS: The pretest scores indicated the residents' preparation and understanding of the session, which improved as the course progressed. The residents' satisfaction surveys graded on a scale from 1 to 5, syllabus content, syllabus effectiveness, teaching expectations, technical demonstrations, practice sessions, confidence gained, and bench model fidelity indicated a mean of 4.09 (standard deviation = 0.81) satisfaction with the new course. Similarly, preceptors' satisfaction surveys graded on a scale from 1 to 5 demonstrated a mean of 4.16 (standard deviation = 0.69) satisfaction. CONCLUSIONS: Surgical skills and CanMEDS roles of communication, professionalism, collaborator and manager, can be taught simultaneously proving that this new teaching format can be feasible, effective, and logistically convenient, providing a satisfying experience for both residents and preceptors.

Development of an orthopedic surgery trauma patient handover checklist.

BACKGROUND: In surgery, preoperative handover of surgical trauma patients is a process that must be made as safe as possible. We sought to determine vital clinical information to be transferred between patient care teams and to develop a standardized handover checklist. METHODS: We conducted standardized small-group interviews about trauma patient handover. Based on this information, we created a questionnaire to gather perspectives from all Canadian Orthopaedic Association (COA) members about which topics they felt would be most important on a handover checklist. We analyzed the responses to develop a standardized handover checklist. RESULTS: Of the 1106 COA members, 247 responded to the questionnaire. The top 7 topics felt to be most important for achieving patient safety in the handover were comorbidities, diagnosis, readiness for the operating room, stability, associated injuries, history/mechanism of injury and outstanding issues. The expert recommendations were to have handover completed the same way every day, all appropriate radiographs available, adequate time, all appropriate laboratory work and more time to spend with patients with more severe illness. CONCLUSION: Our main recommendations for safe handover are to use standardized checklists specific to the patient and site needs. We provide an example of a standardized checklist that should be used for preoperative handovers. To our knowledge, this is the first checklist for handover developed by a group of experts in orthopedic surgery, which is both manageable in length and simple to use.

CONTEXTE: En chirurgie, le transfert préopératoire des polytraumatisés nécessitant une chirurgie est un processus que l'on doit rendre aussi sécuritaire que possible. Nous avons voulu déterminer quels renseignements cliniques vitaux doivent être transmis aux équipes de soins et préparer une liste de vérification standardisée à cette fin. MÉTHODES: Nous avons réalisé des entrevues standardisées par petits groupes au sujet du transfert des polytraumatisés. À partir des renseignements recueillis, nous avons élaboré un questionnaire pour obtenir le point de vue de tous les membres de l'Association canadienne d'orthopédie (ACO) au sujet des éléments jugés les plus importants sur une liste de vérification en vue du transfert. Nous avons analysé les réponses pour dresser une liste de vérification standardisée. RÉSULTATS: Sur les 1106 membres de l'ACO, 247 ont répondu au questionnaire. Les 7 éléments jugés les plus importants pour assurer la sécurité des patients lors du transfert ont été : comorbidités, diagnostic, état de préparation pour le bloc opératoire, stabilité, blessures connexes, histoire et mécanisme du traumatisme et questions en suspens. Les recommandations des experts ont été les suivantes : que les transferts s'effectuent de la même façon chaque jour, qu'on obtienne toutes les radiographies appropriées disponibles, qu'on dispose de temps suffisant, qu'on obtienne toute les analyses de laboratoire appropriées et qu'on aie plus de temps à consacrer aux patients plus grièvement blessés. CONCLUSION: Nos principales recommandations pour un transfert sécuritaire sont d'utiliser des listes de vérification standardisées spécifiques aux besoins des patients et des sites. Nous fournissons un modèle type de liste de vérification pour les transferts qui devrait être utilisée pour le transfert en chirurgie des polytraumatisés. À notre connaissance, il s'agit de la première liste de vérification rapide et simple mise au point à cette fin par un groupe d'experts en chirurgie orthopédique.

Feasibility and fidelity of practising surgical fixation on a virtual ulna bone.

BACKGROUND: Surgical simulators provide a safe environment to learn and practise psychomotor skills. A goal for these simulators is to achieve high levels of fidelity. The purpose of this study was to develop a reliable surgical simulator fidelity questionnaire and to assess whether a newly developed virtual haptic simulator for fixation of an ulna has comparable levels of fidelity as Sawbones. METHODS: Simulator fidelity questionnaires were developed. We performed a stratified randomized study with surgical trainees. They performed fixation of the ulna using a virtual simulator and Sawbones. They completed the fidelity questionnaires after each procedure. RESULTS: Twenty-two trainees participated in the study. The reliability of the fidelity questionnaire for each separate domain (environment, equipment, psychological) was Cronbach α greater than 0.70, except for virtual environment. The Sawbones had significantly higher levels of fidelity than the virtual simulator (p < 0.001) with a large effect size difference (Cohen d < 1.3). CONCLUSION: The newly developed fidelity questionnaire is a reliable tool that can potentially be used to determine the fidelity of other surgical simulators. Increasing the fidelity of this virtual simulator is required before its use as a training tool for surgical fixation. The virtual simulator brings with it the added benefits of repeated, independent safe use with immediate, objective feedback and the potential to alter the complexity of the skill.

CONTEXTE: Les simulateurs chirurgicaux offrent un environnement sécuritaire pour apprendre et pour exercer les habiletés psychomotrices. L'un des objectifs de ces simu - lateurs est de produire des degrés élevés de fidélité. Le but de cette étude était de mettre au point un questionnaire fiable sur la fidélité des simulateurs chirurgicaux et de vérifier si un nouveau simulateur virtuel, avec interface haptique, pour la fixation du cubitus présentait des taux de fidélité comparables à ceux du simulateur Sawbones. MÉTHODES: Des questionnaires sur la fidélité des simulateurs ont été préparés. Nous avons procédé à une étude randomisée stratifiée auprès de stagiaires en chirurgie qui ont effectué une fixation du cubitus à l'aide du simulateur virtuel et à l'aide du simulateur Sawbones. Ils ont répondu au questionnaire sur la fidélité après chaque intervention. RÉSULTANTS: Vingt-deux stagiaires ont participé à l'étude. La fiabilité du questionnaire sur la fidélité pour chaque domaine distinct (environnement, équipement, dimension psychologique) correspondait à un coefficient α Cronbach supérieur à 0,70, sauf pour ce qui est de l'environnement virtuel. Le simulateur Sawbones a présenté des taux de fidélité significativement plus élevés que le simulateur virtuel (p < 0,001), avec une différence importante au plan de la taille de l'effet (indice d de Cohen < 1,3). CONCLUSIONS: Le nouveau questionnaire sur la fidélité s'est révélé un outil fiable qui peut servir à déterminer le degré de fidélité d'autres simulateurs chirurgicaux. Il faudra améliorer la fidélité de ce simulateur virtuel avant de pouvoir l'utiliser comme outil de formation pour la fixation chirurgicale. Ce simulateur virtuel a l'avantage de permettre des utilisations sécuritaires répétées et indépendantes avec des résultats immédiats et objectifs et de modifier la complexité de l'habileté.

Multisource feedback to assess surgical practice: a systematic review.

BACKGROUND: The assessment, maintenance of competence, and recertification for surgeons have recently received increased attention from many health organizations. Assessment of physicians' competencies with multisource feedback (MSF) has become widespread in recent years. The aim of the present study was to investigate further the use of MSF for assessing surgical practice by conducting a systematic review of the published research. METHODS: A systematic literature review was conducted to identify the use of MSF in surgical settings. The search was conducted using the electronic databases EMBASE, PsycINFO, MEDLINE, PubMed, and CINAHL for articles in English up to August 2012. Studies were included if they reported information about at least 1 out of feasibility, reliability, generalizability, and validity of the MSF. RESULTS: A total of 780 articles were identified with the initial search and 772 articles were excluded based on the exclusion criteria. Eight studies met the inclusion criteria for this systematic review. Reliability (Cronbach α ≥ 0.90) was reported in 4 studies and generalizability (Ep2 ≥ 0.70) was reported in 4 studies. Evidence for content, criterion-related, and construct validity was reported in all 8 studies. CONCLUSION: MSF is a feasible, reliable, and valid method to assess surgical practice, particularly for nontechnical competencies such as communication skills, interpersonal skills, collegiality, humanism, and professionalism. Meanwhile, procedural competence needs to be assessed by different assessment methods. Further implementation for the use of MSF is desirable.

A comparison of orthopaedic resident performance on surgical fixation of an ulnar fracture using virtual reality and synthetic models.

BACKGROUND: Surgical trainees develop surgical skills using various techniques, with simulators providing a safe learning environment. Fracture fixation is the most common procedure in orthopaedic surgery, and residents may benefit from simulated fracture fixation. The performance of residents on a virtual simulator that allows them to practice the surgical fixation of fractures by providing a sense of touch (haptics) has not yet been compared with their performance using other methods of practicing fracture fixation, such as a Sawbones simulator model. The purpose of this study was to assess whether residents performed similarly on a newly developed virtual simulator compared with a Sawbones simulator fracture fixation model. METHODS: A stratified, randomized controlled study involving twenty-two orthopaedic surgery residents was performed. The residents were randomized to first perform surgical fixation of the ulna on either the virtual or the Sawbones simulator, after which they performed the same procedure on the other simulator. Their performance was evaluated by examiners experienced in fracture fixation who completed a task-specific checklist, global rating scale (GRS) form, and time-to-completion record for each participant on each simulator. RESULTS: Both simulators distinguished between differing experience levels, demonstrating construct validity; for the Sawbones simulator, the Cohen d value (effect size) was >0.90, and for the virtual simulator, d was >1.10 (p < 0.05 for both). The participants achieved significantly better scores on the virtual simulator compared with the Sawbones simulator (p < 0.05) for all measures except time to completion. The GRS scores showed a high level of internal consistency (Cronbach α, >0.80). However, Pearson product-moment correlation analysis showed no significant correlations between the results on the two simulators; therefore, concurrent validity was not achieved. CONCLUSIONS: The newly developed virtual ulnar surgical fixation simulator, which incorporates haptics, shows promise for helping surgical trainees learn and practice basic skills, but it did not attain the same standards as the current standard Sawbones simulator. The procedural measures used to assess resident performance demonstrated good reliability and validity, and both the Sawbones and the virtual simulator showed evidence of construct validity.

Using simulation to improve the cognitive and psychomotor skills of novice students in advanced laparoscopic surgery: a meta-analysis.

Advances in simulation technologies have enhanced the ability to introduce the teaching and learning of laparoscopic surgical skills to novice students. In this meta-analysis, a total of 18 randomized controlled studies were identified that specifically looked at training novices in comparison with a control group as it pertains to knowledge retention, time to completion and suturing and knotting skills. The combined random-effect sizes (ESs) showed that novice students who trained on laparoscopic simulators have considerably developed better laparoscopic suturing and knot tying skills (d = 1.96, p < 0.01), conducted fewer errors (d = 2.13, p < 0.01), retained more knowledge (d = 1.57, p < 0.01) than their respective control groups, and were significantly faster on time to completion (d = 1.98, p < 0.01). As illustrated in corresponding Forest plots, the majority of the primary study outcomes included in this meta-analysis show statistically significant support (p < 0.05) for the use of laparoscopic simulators for novice student training on both knowledge and advanced surgical skill development (28 of 35 outcomes, 80%). The findings of this meta-analysis support strongly the use of simulators for teaching laparoscopic surgery skills to novice students in surgical residency programs.

The effect of simulation in improving students' performance in laparoscopic surgery: a meta-analysis.

BACKGROUND: There is increasing interest in using simulators for laparoscopic surgery training, and simulators have rapidly become an integral part of surgical education. METHODS: We searched MEDLINE, EMBASE, Cochrane Library, and Google Scholar for randomized controlled studies that compared the use of different types of simulators. The inclusion criteria were peer-reviewed published randomized clinical trials that compared simulators versus standard apprenticeship surgical training of surgical trainees with little or no prior laparoscopic experience. Of the 551 relevant studies found, 17 trials fulfilled all inclusion criteria. The effect sizes (ES) with 95 % confidence intervals [CI] were calculated for multiple psychometric skill outcome measures. RESULTS: Data were combined by means of both fixed- and random-effects models. Meta-analytic combined effect size estimates showed that novice students who trained on simulators were superior in their performance and skill scores (d = 1.98, 95 % CI: 1.20-2.77; P < 0.01), were more careful in handling various body tissue (d = 1.08, 95 % CI: 0.36-1.80; P < 0.01), and had a higher accuracy score in conducting laparoscopic tasks (d = 1.38, 95 % CI: 0.30-2.47; P < 0.05). CONCLUSION: Simulators have been shown to provide better laparoscopic surgery skills training for trainees than the traditional standard apprenticeship approach to skill development. Surgical residency programs are highly encouraged to adopt the use of simulators in teaching laparoscopic surgery skills to novice students.

A meta-analysis of common risk factors associated with the diagnosis of developmental dysplasia of the hip in newborns.

BACKGROUND: Although there is no clear consensus about the process of screening for developmental dysplasia of the hip (DDH), there are six common risk factors associated with DDH in patients less than 6 months of age (breech presentation, sex, family history, first-born, side of hip, and mode of delivery). METHODS: A meta-analysis of published studies was conducted to identify the relative risk ratio of the six commonly known risk factors. A total of 31 primary studies consisting of 20,196 DDH patients met the following inclusion criteria: (1) contained empirical data on at least one common risk factor, (2) were peer-reviewed from an English language scientific journal, (3) included patients less or equal to 6 months of age, and (4) identified method of diagnosis (e.g., ultrasound, radiographs or clinical examination). RESULTS: Fixed effect and random effects models with 95% confidence intervals were calculated for each of the six risk factors. Reported relative risk ratio (RR) for each factor in newborns was: breech presentation 3.75 (95% CI: 2.25-6.24), females 2.54 (95% CI: 2.11-3.05), left hip side 1.54 (95% CI: 1.25-1.90), first born 1.44 (95% CI: 1.12-1.86), and family history 1.39 (95% CI: 1.23-1.57). A non-significant RR value of 1.22 (95% CI: 0.46-3.23) was found for mode of delivery. CONCLUSION: Results suggest that ultrasound and radiology screening methods be used to confirm DDH in newborns that present with one or a combination of the following common risk factors: breech presentation, female, left hip affected, first born and family history of DDH.

A teaching model for aromatase inhibitors after tamoxifen.

Breast cancer is the most common cancer diagnosed in women. The present study evaluated the family physicians' (FPs) understanding of adjuvant hormonal therapies for an early breast cancer. FPs were invited to attend teaching workshops on this topic, which utilized a pretest, didactic and interactive teaching, and posttest format. FPs (n = 23) showed an improvement (p < 0.001) in pretest to posttest score. It is clear that, with a targeted teaching, FPs can quickly become more knowledgeable on the topic of hormonal therapies in breast cancer, with the potential of applying this information in their own practice.

Procedural skills education--colonoscopy as a model.

Traditionally, surgical and procedural apprenticeship has been an assumed activity of students, without a formal educational context. With increasing barriers to patient and operating room access such as shorter work week hours for residents, and operating room and endoscopy time at a premium, alternate strategies to maximizing procedural skill development are being considered. Recently, the traditional surgical apprenticeship model has been challenged, with greater emphasis on the need for surgical and procedural skills training to be more transparent and for alternatives to patient-based training to be considered. Colonoscopy performance is a complex psychomotor skill requiring practitioners to integrate multiple sensory inputs, and involves higher cortical centres for optimal performance. Colonoscopy skills involve mastery in the cognitive, technical and process domains. In the present review, we propose a model for teaching colonoscopy to the novice trainee based on educational theory.

Impact of cognitive imaging and sex differences on the development of laparoscopic suturing skills.

BACKGROUND: The introduction of noninvasive laparoscopic surgery has raised concerns about appropriate teaching techniques for medical students considering surgery as a specialization. The principal aim of this study was to determine the effect, between the sexes, of cognitive imaging as a teaching method in the context of learning a surgical technique. METHODS: A randomized treatment-control sample of 42 medical student volunteers was used to test the effect of cognitive imaging on performance and on traditional instructional techniques to help medical students acquire suturing skills specific to laparoscopic surgery. RESULTS: Repeated-measures analysis of variance showed no significant effect for the use of cognitive imaging (F1,40 = 0.97, p > 0.05). Males tended to perform better than females in completing tasks that required the use of visual-spatial manipulation of the instruments within a simulated laparoscopic environment (F1,40 = 5.08, p < 0.05). CONCLUSIONS: These results, which are in concordance with other research findings, indicate that females generally have lower visual-spatial abilities than males. Enhanced performance for both sexes, however, increases rapidly with practice. Other than verbal one-on-one instruction, males on average rank instructional approaches that are applied and visual higher than do females.